chapter 7: acute & ptsd, dissociative, & somatoform disorders
DESCRIPTION
Chapter 7: Acute & PTSD, Dissociative, & Somatoform Disorders. Fall, 2012 Dr. Mary L. Flett, Instructor. Overview. These disorders, while differing in many ways, share one common similarity: dissociation Limited research on this area Conflicting theories and schools of belief - PowerPoint PPT PresentationTRANSCRIPT
Chapter 7: Acute & PTSD, Dissociative,
& Somatoform Disorders
Fall, 2012
Dr. Mary L. Flett, Instructor
Overview
These disorders, while differing in many ways, share one common similarity: dissociation
Limited research on this area Conflicting theories and schools of belief Lack of empirical research; lots of anecdotal At the core – is the mind all powerful?
Acute & Post-traumatic Stress Disorders (PTSD)
Traumatic stress is defined as an event that involves actual or threatened death or serious injury to self or others, and creates intense feelings of fear, helplessness, or horror Rape Military combat Bombings Airplane crashes Earthquakes Fires Automobile wrecks
Acute & Post-traumatic Stress Disorders (PTSD)
Acute stress disorder occurs within 4 weeks after the exposure and is characterized by: dissociative symptoms re-experiencing the event avoidance of reminders marked anxiety or arousal
PTSD the symptoms are longer lasting or delayed
Acute & Post-traumatic Stress Disorders (PTSD)
Dissociative symptoms in PTSD include feeling dazed or spaced out a marked sense of unreality (derealization) the inability to recall important aspects of the
trauma (dissociative amnesia) numbing or detachment
Acute & Post-traumatic Stress Disorders (PTSD)
Trauma is defined as the experience of an event involving actual or threatened
death or serious injury to self or others a response of intense fear, helplessness, or horror in
reaction to the event Different trauma may have unique psychological
consequences 9/11 experiences suggest those not directly exposed to
trauma suffered at least an acute stress response disaster & emergency workers are less likely to experience
stress response, but do need to attend to their own issues
Acute & Post-traumatic Stress Disorders (PTSD)
Co-morbidity high for depression, other anxiety disorders, and alcohol abuse
Increased suicide risk Differential diagnosis between adjustment
disorder and ASD looks at “normal” reactions to painful stressors such as losing a job
Acute & Post-traumatic Stress Disorders (PTSD)
Frequency of Trauma, PTSD, & ASD Traumatic stressors are common, not rare as
previously believed Women are especially likely to develop PTSD if
raped; men if in combat Children and women more vulnerable to PTSD Members of marginalized communities more likely
to experience PTSD Most common experience is sudden, unexpected
death of a loved one
Acute & Post-traumatic Stress Disorders (PTSD)
Frequency of Trauma, PTSD, & ASD Risk is higher for those who engage in risky
behavior, have a history of conduct disorders, or are extroverts
Individuals who are “neurotic” (anxious and easily upset) more likely to develop PTSD
If previous trauma experienced, vulnerability to a second episode is higher
Family history of mental illness is also a predictor
Acute & Post-traumatic Stress Disorders (PTSD)
Course & Outcome Best predictors of future PTSD
numbing depersonalization sense of reliving the experience
Sx generally diminish over time with greatest improvement seen within first year
Sx may remain, however, for as long as 40-50 years
Acute & Post-traumatic Stress Disorders (PTSD)
Causes Social factors include degree of exposure Lack of support or denial of symptoms Environmental influence is higher than genetic Genes appear to contribute most strongly to
arousal/anxiety symptoms and least strongly to re-experiencing
Acute & Post-traumatic Stress Disorders (PTSD)
Biological Effects of Exposure Consequences include
alterations in functioning and structure of the amygdala Sympathetic nervous system appears to be aroused and the
fear response sensitized in PTSD
No direct evidence of brain damage due to PTSD Damage may be pre-existing Brain trauma is not same as emotional response
Acute & Post-traumatic Stress Disorders (PTSD)
Psychological Factors Two-Factor Theory states that classical
conditioning creates fears when paired; operant conditioning maintains avoidance by reducing fear
Avoidance prevents the extinction of anxiety through exposure
Dissociation may be an unconscious defense that helps cope with the trauma
Acute & Post-traumatic Stress Disorders (PTSD)
Psychological Factors Emotional processing
victim must engage emotionally with the traumatic memory victim must find a way to articulate and organize their chaotic
experience victim must come to believe that, despite their experience, the
world is not a terrible place
Assuming all three steps are completed, victim may experience post-traumatic growth
Acute & Post-traumatic Stress Disorders (PTSD)
Prevention & Treatment Offering immediate psychological help to victims
is a common goal Critical incident stress debriefing (CISD)
designed to intervene as closely to the event as possible if done correctly, may mitigate symptoms, but no evidence to
support assertion that CISD prevents PTSD if done poorly, may actually exacerbate symptoms
Returning to normal routine quickly appears to be beneficial, whether this is combat or work
Acute & Post-traumatic Stress Disorders (PTSD)
Treatment of ASD not well researched; PTSD has received more study
Most effective treatment for PTSD is re-exposure to trauma confronting feared situations imagery rehearsal therapy prolonged exposure emotional processing & making meaning
Acute & Post-traumatic Stress Disorders (PTSD)
Eye movement desensitization & reprocessing (EMDR) is another technique Has research validity Is as effective as prolonged exposure May be ineffective in hands of poorly trained
therapist
Dissociative Disorders
Dissociative disorders are characterized by persistent, maladaptive disruptions in the integration of memory, consciousness, or identity May be all “hooey” May be legitimate, and under reported May be rare
Dissociative Disorders
Hysteria & the Unconscious From the Greek for uterus (hystera); reflects
ancient view that a woman’s desire to have a baby, when frustrated, cause these symptoms
Freud (Charcot & Janet) all believed that hysteria could be treated by hypnosis Freud considered dissociation from reality to be a normal
process; an expression of unconscious conflict Janet believed it was a pathological process Freud had better media exposure and his theory dominated
Dissociative Disorders
Current research on “the unconscious” Explanations include
rational and experiential systems (Epstein) implicit and explicit memory (Schacter)
Hypnosis & altered states of consciousness Suggestibility? Dissociative experience?
Dissociative Disorders
Symptoms of Dissociative Disorders Depersonalization Psychogenic amnesia
inability to recall events, persons, or emotions associated with a trauma
Dissociative Fugue sudden, unplanned travel, the inability to remember details
about the past, and confusion about identity or the assumption of a new identity
Recovered memory
Dissociative Disorders
Diagnosis of Dissociative Disorders Four subtypes found in DSM
Dissociative fugue (travel away from home; inability to recall) Dissociative amnesia (sudden inability to recall extensive &
important personal information) Depersonalization disorder (feelings of being detached from
self) Dissociative Identity Disorder (DID) (existence of two or more
“personalities” within one individual
Dissociative Disorders
Frequency of Dissociative Disorders Dominant thinking is that these are very, very rare Minority thinking makes a strong case that
individuals are mis-diagnosed (schizophrenics, BPD, et al) and not being treated
Other explanations include role enactment
Dissociative Disorders
Causes Psychological Factors
precipitated by a traumatic experience state-dependent learning
Biological Factors Little evidence has been gathered
Social Factors iatrogenesis – the manufacture of a disorder by its treatment
Dissociative Disorders
Treatment Focus is on uncovering and recounting traumatic
events assumes that if trauma can be expressed, need for
dissociative coping will disappear
Integrating all personalities into a single whole No systematic research on any one approach has
been collected
Somatoform Disorders
Symptoms Complaints about physical symptoms that are
“real”, but no medical evidence of the cause can be identified May involve substantial impairment of sensory or muscular
system (blindness or paralysis) Chronic pain, upset stomach, dizziness Preoccupation with a particular part of the body or fears of a
particular illness
Somatoform Disorders
Unnecessary medical treatment Primary care is point of access Difficult to evaluate objectively Result in unnecessary surgery and laboratory
testing May account for ½ of all ambulatory care costs
Somatoform Disorders
Diagnosis Five subcategories
Conversion Disorder (hysterical blindness; paralysis) Somatization Disorder (history of multiple somatic complaints
in the absence of organic impairments) histrionic la belle indifference
Hypochondriasis (fear of suffering from physical illness) Pain Disorder (preoccupation with pain) Body Dysmorphic Disorder (preoccupation with a particular
body part)
Somatoform Disorders
Diagnosis Malingering & Factitious Disorders
Not a psychological problem; intentional, conscious roles Motivated by desire to assume the sick role (factitious
disorder, aka Munchausen Syndrome) Pretending to be ill to achieve some external gain
(Malingering)
Somatoform Disorders
Frequency Lower prevalence today due to improved
diagnostic practices No longer hysteria; now possibly chronic fatigue
syndrome, Gulf War syndrome New category (multisomatoform disorder) is
proposed for DSM-V
Somatoform Disorders
Gender, SES, and Culture More common among women, particularly
somatization disorder More common among lower socio-economic
groups, and psychological unsophisticated individuals
Cultural implications arise where culture does not allow free expression of emotions, but does accept body pains
Somatoform Disorders
Co-morbidity Occur particularly with depression and anxiety Frequently linked to antisocial personality disorder
Usually found in different members of the family, not one individual
Somatoform Disorders
Causes Biological Factors
real potential for misdiagnosis diagnosis by exclusion Conversion disorder may resolve into a known physical
disorder (epilepsy, neurological disease)
Psychological Factors May be triggered by trauma, but not necessarily Extra attention; avoidance of undesirable activity Adopting the “sick role”
Somatoform Disorders
Causes Social Factors
Emotional expression of distress may be unacceptable
Somatoform Disorders
Treatment Operant approaches to chronic pain alter reward
system for “pain behavior” CBT uses cognitive restructuring to address
emotional and thought components of pain Anti-depressants are helpful Lack of research due to fact that primary care
physicians do most of treatment without partnering with psychologists Patients shop for sympathetic doctors to treat them adding
costs to care